The Care Quandary: Six months. $1.2 million. Was it worth it?

A young physician ushered the three siblings into a consultation room at Mercy Hospital St. Louis.

Their mother, Althlee Williams, 89, had fallen into a coma. Her eyes were shut. She couldn't speak. A machine pumped her lungs.

It was time, the doctor told them. They should let their mother die.

For months, they had watched her suffer through rashes and bedsores, heart stoppages and breathing problems. Her weight fluctuated by 100 pounds. Williams' two daughters agonized, but seemed ready. Their brother, Clayton Williams Jr., refused.

"Don't take her off. ... Do whatever you can," he said, before bolting out of the room.

Such wrenching dilemmas test not only family bonds and the frontiers of medicine, but the nation's tolerance for runaway health care costs. In the final six months of her life, Williams' care totaled about $1.2 million,

according to billing records provided by the family.

With the fate of the national health care overhaul now in the hands of the Supreme Court, many experts agree that the ethical and financial dynamics of dying should remain at the center of the national health debate. Yet few politicians, bureaucrats, insurers and doctors dare even to discuss it. And no one seems to have a clue as to how our society can afford to pay national health costs that approached $2.6 trillion in 2010 -- a tenfold increase since 1980, according to the Centers for Medicaid and Medicare Services.

"With more elderly people coming, as the baby boomers come into Medicare, it's only going to get worse," said Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania.

End-of-life care issues go far deeper than money. Even two years after their mother's death, Williams' children remain troubled by concerns that all that care did little but prolong her suffering. Beyond political and financial pressures, their mother's case lays bare the ethical complexities of the question that so many families must ultimately face.

For months, the three siblings had rearranged their work and family schedules to help their mother navigate a maze of hospitalizations, blood transfusions, drugs, side effects, infections and dialysis. They looked after her in shifts, with Vivian Ransburg taking most of the day, her sister taking over in the late afternoon, and her brother staying in his mother's room through every night.

They winced with frustration when nurses pricked her fingers to test her blood sugar, and watched her slowly lose her mind to Alzheimer's. When she couldn't swallow pureed food, they allowed doctors to install a surgically implanted feeding tube in her stomach. When her breathing grew short four months before she died, they agreed to put her on a respirator.

Their mother's health only got worse during the repeated hospitalizations, and she often suffered despite extraordinary measures to comfort and save her.

"It was not a comfortable or peaceful death," said Williams' younger daughter, former speech pathologist Teresa Rice Scurlock of University City. "It was just prolonged."

'A BOTTOMLESS PIT'

Cost never appeared to enter into the decisions about Williams' care; the hospital billed Medicare and a supplemental insurance plan.

When the elderly can survive only with aggressive measures, the incentives for all involved tilt toward treatment, regardless of cost. Family members naturally want loved ones to live. Physicians and hospitals get paid well for providing extensive medical treatment -- and face legal liability for denying care, even if the patient has scant survival prospects. Insurance companies likewise fear being vilified and sued for denied care, and can preserve profit margins by passing along the costs to employers and their workers. And the Medicare program ultimately reports to Congress, which has shown no willingness to wade into the political deadly arena of near-death care -- or curbing federal health entitlements at all.

While steep, Williams' health care tab is hardly unique in an era of rapidly advancing medical technology that hospitals increasingly apply to prolong life.

"A million bucks for an extended (hospital) stay, sadly, is not out of the norm," said Samuel Steinberg, a hospital consultant based in Florida. "Several weeks in intensive care could be a million bucks."

"The bad news is that Medicare is essentially a bottomless pit," he said. "The hospital can keep admitting her and testing her as long as they choose."

The Supreme Court's expected decision this month on the constitutionality of President Barack Obama's health reform law will no doubt affect the cost and delivery of medical care. But regardless of how justices rule, the volatile issues surrounding end-of-life care for the elderly will remain largely unaddressed.